Appendix D

/ Vapor Intrusion
Building SurveyForm
Remediation Program
Doc Type: Site Inspection Information
Preparer’s name: / Date/Time prepared:
Affiliation: / Phone number:
Email:

Part 1: Property owner & building occupant information

1. Owner/Landlord information (Check if same as occupant: )

Occupant name(s): / Interviewed: / Yes No
Mailing address:
City: / State: / Zip code:
Home phone: / Office phone:

2. Occupant information

Occupant name(s): / Interviewed: / Yes No
Mailing address:
City: / State: / Zip code:
Phone: / Fax: / Email:
Number of occupants at this location: / Age range of occupants:

Part 2: Building evaluation

3. Building use (Check appropriate response)

Residential Child/Day Care School Church Hospital Long-term care facility Correctional facility
Commercial Industrial
Other (specify):

If the property is residential, what type? (Check appropriate response)

Ranch rambler Raised rambler Townhouses/Condos Duplex Modular 2-Family
Split level Contemporary Apartment house Cape cod Log home 3-Family
Colonial Mobile home Other (specify):

4. Building description

If the property is commercial or industrial, describe the business use(s):
Indicate the number of floors and general use of each floor of the building beginning with lowest level:
If there are multiple residential units, indicate how many units: / When was building constructed:
Type of insulation used in building: / Elevators or lifts: / Yes No
Basement/Lowest level depth below grade: / (feet)

Observed basement characteristics (Check all that apply)

Is basement/lowest level occupied: / Full time / Occasionally / Almost never
Bedrooms in the basement/lowest level: / Yes No / If yes, are the bedrooms occupied regularly: Yes No
Basement type: / Full / Partial / Slab / Other:
Floor materials: / Concrete / Dirt / Stone / Other:
Floor covering: / Uncovered / Covered / Covered with:
Concrete floor: / Unsealed / Sealed / Sealed with:
Foundation walls: / Poured / Block / Stone / Other:
Basement finished: / Unfinished / Finished / Partially finished
Basement wetness: / Wet / Damp / Seldom / Moldy
Sump pump present: / Yes No / If yes, was water present: Yes No
Are there any crawl spaces present: / Yes No / If yes, describe the crawl space floor conditions (earth, concrete, etc.) and construction (walls, use, connectivity to building, etc.) and illustrate location on the attached grid plans:
Have there been any building additions / Yes No / Describe addition construction including how it ties to the existing floor plan (footings, slab connectivity, etc.) illustrate locations of additions on the attached grid plans:
Thickness of the concrete floor slab in the lowest level(s): / Inches.
Soil type present beneath the building:
Is there evidence of saturated or high moisture conditions beneath the floor slab? Yes No
If yes, explain:

Indicate sources of water supply sources (i.e., drinking, irrigation, etc.) and type of sewage disposal
(Check all that apply)

Water supply: / Public water / Drilled well / Driven well / Dug well
Sewage disposal: / Public sewer / Septic tank / Leach field / Dry well

5. Heating, venting, air conditioning, or other building controls (Check all that apply)

Type of heating system(s) used in this building (Check all that apply)

Hot air circulation Space heaters Electric baseboard In-floor heating Heat pump
Steam radiation Wood stove Hot water baseboard Radiant floor Outdoor wood boiler
Other (specify): / Primary type:

Primary type of fuel used (Check appropriate response)

Natural gas Fuel oil Kerosene Electric Propane
Solar Wood Coal
If hot water tank present, indicate fuel source:
Boiler/furnace is located in: / Basement / Outdoors / Main floor / Other:
Type of air conditioning: / Central air / Window units / Open windows / No mechanical system
Is outside replacement (make-up) air provided for combustion appliances? Yes No
If no, explain:
Are there air distribution ducts present? Yes No
Describe the supply and cold air return ductwork and its condition where visible, including whether there is a cold air return and the tightness of duct joints. Indicate the locations on the floor plan diagram:
Describe the type of mechanical ventilation systems used within or for the building (e.g., air-to-air exchangers, HVAC, etc.). Indicate whether the interior spaces of the building use separate ventilation systems and/or controls. Provide information on any existing building mitigation system (e.g., radon mitigation, passive venting systems, etc.). If available, provide information on air exchange rates for any existing mechanical ventilation systems currently in use.

6. Summary of potential building vapor intrusion entry points

Earthen floors or incompetent floor slabs in the lowest level of building Yes No

Sumps (unsealed) Yes No

Large utility penetrations through floor and/or walls with exposure to sub-surface soils Yes No

Crawl spaces with earthen floors or incompetent floor conditions Yes No

Other (describe) Yes No

7. Is the use of the vapor intrusion attenuation factor (33X ISV screening level) valid for this building based on the above building conditions? Yes No

8. Grid plans

Use grid plans to describe floor plans, locate potential soil vapor entry points (e.g., cracks, utility ports, drains); and if applicable, identify sample locations (sub-slab, indoor air, outdoor air sampling).

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Appendix D

Floor plan for basement or lowest level at property address:
Scale: / North (indicate direction):
Floor above lowest level at property address:
Scale: / North (indicate direction):

Outdoor grid plot (Include if outdoor ambient air samples collected):

Insert sketch (or attach separate document) of the area outside the building and locate outdoor air sample locations.
If applicable, provide information on spill locations, potential air contamination sources, locations of wells, septic system, etc., and PID meter readings. Indicate wind direction and speed during sampling.

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Appendix D

Part 3: Indoor Air Quality Survey

Complete if indoor air sampling is conducted (use grids in Part 1 for labeling sampling locations).

Factors that may influence indoor air quality:

Is there an attached garage: / Yes No
Are petroleum-powered machines or vehicles stored in the garage (e.g., lawn mower, ATV, car): / Yes No / Please specify:
Has the building ever had a fire: / Yes No / When:
Is a kerosene or unvented gas space heater present: / Yes No / Where & type:
Is there smoking in the building: / Yes No / How frequently:
Have cleaning products been used recently: / Yes No / When & type:
Have cosmetic products been used recently: / Yes No / When & type:
Has painting/staining been done in the last 6 months: / Yes No / Where & when:
Has any remodeling or construction occurred in the last 6 months: / Yes No / Where & when:
Is there new carpet, drapes, or other textiles: / Yes No / Where & when:
Have air fresheners been used recently: / Yes No / When & type:
Is there a clothes dryer: / Yes No / If yes, is it vented outside:
Are there odors in the building: / Yes No / If yes, please describe:
Do any of the building occupants use solvents at work: / Yes No
If yes, what types of solvents are used:
Do any of the building occupants regularly use or work at a dry-cleaning service: / Yes No
If yes, indicate approximately how frequent:

Product inventory form (Add additional rows if needed)

Make and model of field instrument used:

List specific products identified in the building that have the potential to affect indoor air quality (add or delete rows as needed):

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Appendix D

Location / Product description* / Comments / Instrument readings if taken and units

* Describe the condition of the product containers as Unopened (UO), Used (U), or Deteriorated (D).
Include photographs of product containers as appropriate to document products and ingredients.

Location / Product description* / Comments / Instrument readings if taken and units

* Describe the condition of the product containers as Unopened (UO), Used (U), or Deteriorated (D).
Include photographs of product containers as appropriate to document products and ingredients.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred realy service • Available in alternative formats

c-rem3-01a • 10/28/16 Page 1 of 8